Reining in cowboys of complementary medicine

Author

NHMRC Research Scholar, School of Population Health , The University of Queensland

Disclosure statement

Jon Wardle receives funding from the National Health and Medical Research Council. He is affiliated with the Australian Register of Naturopaths and Herbalists, an independent register being developed to redress the shortfalls in government regulation of these professions.

Despite increasing uptake of complementary medicine, professions within its range remain unregulated, undocumented and their impact on health generally unknown.

This has created an informal ‘black market’ in Australian healthcare so the government is currently consulting
on developing legislation for unregistered CAM practitioners.

Although policy has failed to keep up, complementary and alternative medicine (CAM) has gone mainstream in Australia. We are amongst the world’s highest users of CAM providers, with 10% of the population regularly consulting naturopaths.

Complementary medicine forms half of the healthcare sector in Australia. Australians are more likely be seeing a CAM practitioner than not, and they are very likely avoiding discussing this with their doctor.

Open a newspaper or magazine, watch television or listen to the radio and you are just as likely to hear from an acupuncturist, naturopath or massage therapist commenting on health as you are a medical doctor or other ‘conventional’ provider. CAM practitioners are here to stay and can no longer be conveniently ignored by policy makers.

How regulation will help

The role of regulation is to protect the public from undue risk. It can do this through proactive mechanisms, such as ensuring minimum standards or reactive mechanisms, such as disciplinary action.

The new legislation will most likely be based on the New South Wales Code of Conduct for Unregistered Practitioners,
which allows health complaints authorities to prosecute health practitioners in breach of a statutory code of conduct. Currently, most health care complaints authorities apart from NSW have no statutory authority to prosecute health practitioners.

While this legislation can remove people not fit to practice from unregistered health professions, it can only act after the fact. In essence, it is shutting the gate after the horse has bolted.

Developments such as the introduction of a statutory code of conduct for unregistered practitioners is an improvement, but they are reactive catch-all systems designed to fill gaps, and should not replace proper regulation.

Risks common to all medical professions include financial exploitation through over-prescribing or over-servicing or inappropriate contact during a consultation. But unlike regulated professions, there is no mechanism to hold CAM practitioners accountable.

Monopolisation of care

In CAM professions, major risks come from acts of omission due to their primary care role, such as failure to refer when appropriate, rather than acts of commission through the specific treatments used.

For instance, a man presenting with a head wound was unsuccessfully treated by a Cairns naturopath for so long that by the time he eventually consulted with a medical professional, infection had reached the meninges of his brain.

Here harm resulted not from the naturopath’s actual treatment, but the failure to refer for more appropriate treatment sooner in what should have been picked up as a ‘red flag’ situation. This situation could easily have been averted through ensuring adequate training for the naturopath in health sciences.

There are countless examples of patients harmed in this manner, with some resulting in death.

A Newcastle infant died after a naturopath claimed to be able to cure a congenital heart defect with herbal drops and advised the parents not to go ahead with surgery.

The Melbourne Royal Children’s Hospital has reported cases of children dying or being seriously harmed after CAM practitioners tell parents to cease conventional treatment for cancer or epilepsy and focus exclusively on CAM treatments.

Regulation will make such practitioners legally responsible for their failure to refer. Under current arrangements, unless patients are willing to go through a long, drawn-out civil proceeding, there are very few options to hold practitioners accountable for such malpractice.

Sometimes victims are even seen as ‘having it coming’ for seeing an unregistered practitioner in the first place.

Shifting focus onto the actions of the practitioner in these cases was the major reason the Canadian government recently extended statutory regulation to naturopaths, homoeopaths and Chinese medicine practitioners.

Risk of therapies

Some herbal or nutritional medicines can cause harm if used incorrectly while physical therapies like manipulation or deep-tissue massage may cause harm if performed by unqualified practitioners, as can insertion of needles.

Even when therapies are generally safe they may interact with conventional medications. This is especially profound in areas that require very specific doses of medicines, such as chemotherapy.

Many CAM therapies do offer great benefit for the patients who choose them, so shouldn’t be excluded entirely. Ensuring minimum standards of education can ensure CAM practitioners know how to deliver these therapies safely. And regulation can ensure they are held responsible when they don’t.

The failure of self-regulation

Self-regulation of CAM practitioners has generally been viewed as a failure. This is partly due to the fragmentation of CAM professions. Over 90 professional associations claim to represent naturopaths alone though ‘only’ 28 are recognised by the government.

But government recognition does not require minimum standards, only that standards do not differ between states.

Many courses for CAM practitioners that are eligible for FEE-HELP do not meet minimum World Health Organization (WHO) benchmarks for training in those professions.

Arguments among CAM professional associations over professional standards have generally led to a ‘lowest common denominator approach’, which falls short of promoting public interest.

Ideological, philosophical and historical differences mean that many associations will not even work together, even when compelled to.

As part of the condition of receiving GST-free status for consultations, naturopathy, herbal medicine and acupuncture associations were given $500,000 by the Federal government to create national uniform standards and develop an independent register. But professional divisions destroyed this process and it hasn’t yet been completed.

Myriad conflicts of interests also exist in current self-regulatory arrangements.

Australia’s largest CAM professional association represents college owners rather than practitioners, who are, in effect accrediting their own courses. This may explain their opposition to further regulation – some colleges will most likely incur significant costs in bringing their curriculum up to an acceptable level.

One professional association refused to deregister a practitioner who had falsified his qualifications and had a history of fraud and armed robbery after receiving complaints he was exploiting patients because it was afraid of being sued.

Available models

Major models for regulating health practitioners are self-regulation, co-regulation and statutory regulation.

Self-regulation allows professions to regulate themselves and is the status quo. Even with introduction of a statutory Code of Conduct, the profession will remain largely self-regulated.

Co-regulation is another model being proposed. This is where government formally recognises professional associations and may even mandate joining a professional association as a requirement to practice. This model is untested and nearly as expensive as statutory regulation.

A number of CAM associations support this model, though this may have more to do with shoring up member numbers and influence than promotion of minimum standards or public protection.

When most people think of ‘regulation’ they are thinking of statutory regulation. This is where a government appoints a Board that sets minimum standards of training and practice, and requires all members of that profession to abide by those standards.

Statutory regulation also offers legal protection of title, requiring anyone using that title to demonstrate they have had appropriate training. Unauthorised use of protected titles is an offence.

This differs from the current arrangements where anyone can call themselves a naturopath, counsellor or any other unregistered profession, with or without the necessary qualifications.

Statutory regulation also simplifies the complaints processes. The introduction of statutory regulation in Chinese medicine saw a ten-fold increase in complaints against these practitioners when a single board became responsible for complaints.

These complaints weren’t new but had been ‘lost in the system’ due to confusing or multiple complaints handling processes.

There is consensus among Australian healthcare complaints authorities that complaints against CAM practitioners are under-reported because of flawed handling processes.

What now?

CAM practitioner regulation has been initiated successfully in Australia previously – chiropractors, osteopaths and Chinese medicine are all part of the National Registration Scheme.

For larger professions such as these, statutory regulation is clearly the ideal scenario.

Self-regulation could be only effective if it were independent or in a profession with one strong association to be effective.

Across all CAM professions, both these scenarios look unlikely because statutory regulation may not be practicable for smaller or ‘new’ emerging professions.

For this reason, the Government’s decision to implement generic ‘catch-all’ legislation is a welcome one but it should complement, not replace further regulation of larger CAM professions.

If the government wishes to afford public protection, regulation will have to begin considering these practitioners at some stage. The public will continue to use their services even if they remain free to practice without any rules or restraint.